CLIENTS WITH

CONGESTIVE
HEART FAILURE

By: CHARLEMAGNE B. PULGAN, RN

 HEART FAILURE
• Heart failure (HF) is a result from structural or functional cardiac
disorders that impair the ability of the ventricles to fill or eject blood
• Currently, HF is recognized as a clinical syndrome characterized by
signs and symptoms of fluid overload or inadequate tissue perfusion.
• Fluid overload and decreased tissue perfusion result when the heart
cannot generate cardiac output (CO) sufficient to meet the body’s
demands for oxygen and nutrients.
 HEART FAILURE
It is a state of circulatory congestion produced by myocardial
dysfunction or myocardial disease
 which impaired contraction of the heart (systolic dysfunction)
or ;
 filling of the heart (diastolic function)
• Therefore, the ability of the ventricle to empty lessens and
resulted to diminished cardiac output and inadequate
peripheral tissue perfusion.
• Congestion of the lungs and periphery may occur
What is CARDIAC OUTPUT?

- the product of heart rate (HR) and stroke volume (SV) and is

measured in liters per minute.
- 5-6 L/min at rest ; 35L/min with exercise

- Heart Rate is most commonly defined as the number of heart beats

in one minute (60 to 100 bpm)

- Stroke Volume is the volume of blood ejected during ventricular

contraction each stroke of the heart (average stroke volume is 70 ml)
Stroke Volume = EDV – ESV Ejection Fraction = SV / EDV x 100
e.g SV= 120 ml -50 ml
SV = 70 ml EF% = 70 ml /120 ml x100
EF = .5833 x 100
EF= 58.33%
Cardiac Output = HR x SV
CO = 75 x 70
EF normal range is 50 percent up
CO = 5,250 ml An ejection fraction below 40% could
mean that the heart is not pumping
Ejection fraction is a enough blood and maybe failing
measurement of the percentage
of blood leaving your heart each
time it squeezes 
 3 FACTORS THAT AFFECT STROKE VOLUME
• Preload: the degree of stretch of the heart muscle at the end of
diastole
• the amount of blood prior to contraction (EDV)
• Afterload: the pressure that the ventricular myocardium must
overcome to eject blood during contraction;
• the pressure that the heart must generate to move blood into the aorta
• Contractility: term used to denote the force generated by the given
condition the ability of muscle cells to contract after receiving
stimulus
 CAUSES OF HEART FAILURE
1. Direct Damage to the Heart (mitral myocarditis, ventricular
aneurysm)
2. Ventricular Overload
• Increased in Preload (mitral and aortic regurgitation, Atrial and
Septal Defects, Rapid Infusion of large volume of IV Fluids)
• Increased Afterload (aortic or pulmonary valve stenosis, systemic
hypertension, pulmonary hypertension
3. Constriction of the ventricles (cardiac tamponade, pericarditis,
restrictive cardiomyopathies)
 CLASSIFICATION OF HEART FAILURE

A. Forward Heart Failure results from inability of the heart

to maintain cardiac output (LEFT-SIDED HEART
FAILURE)
Left-sided heart failure: The left ventricle of the heart no
longer pumps enough blood around the body.
As a result, blood builds up in the pulmonary veins (the
blood vessels that carry blood away from the lungs).
This causes shortness of breath, trouble breathing or coughing
– especially during physical activity.
•LSCHF Causes:
Myocardial Infarction
Hypertension
Aortic Stenosis / Insufficiency
Mitral Stenosis / Insufficiency

Reduced Myocardial Contractility

Increased Cardiac Workload
Decreased Diastolic Filling
Obstruction of Left Atrial Emptying

Increased Left Atrial Pressure

Left -Sided Congestive Heart Failure

 Blood Dams Back into the Pulmonary
Decrease Stroke volume
Capillary Bed

Pressure of Blood Into the Pulmonary

Decrease Tissue Perfusion
Capillary Bed Increases

pressure in these blood vessels increases, fluid is

pushed into the air spaces (alveoli) in the lungs Increase Cellular Hypoxia

Pulmonary Edema
 Decrease Blood flow to kidneys
Signs and Symptoms:
• Dyspnea • Anorexia
RAAS Stimulation
• Paroxysmal Nocturnal • Hypokalemia (due to
Dyspnea increase aldosterone
• Orthopnea level) Vasoconstriction and
• Rales and crackles • Clubbing of Fingers Reabsorption of Sodium and
• Cough • S3S4 heart sounds Water
• Blood-tinged Frothy • Pulsus Alterans
Sputum • Elevated Pulmonary
• Wheezing Artery Pressure, Increase Extra Cellular
• Dizziness Pulmonary Capillary volume
• Syncope (fainting) Wedge Pressure (Swan-
• Fatigue Ganz Catheter) 1. Increase Total Blood
Volume
2. Increase Systemic BP
 CLASSIFICATION OF HEART FAILURE

B. Backward Heart Failure results from damming up of blood

in the vessels
Right-Sided Heart Failure: The right ventricle is too weak
to pump enough blood to the lungs.
As a result: Blood builds up in your veins, vessels that carry
blood from the body back to the heart.
This buildup increases pressure in your veins
•RSCHF Causes:
LSCHF
Pulmonary Embolism
Right Ventricular Infarction
Congenital Septal Defect

Reduced Myocardial Contractility

Increased Cardiac Workload
Decreased Diastolic Filling
Obstruction of Right Atrial Emptying

Increased Right Atrial Pressure

Right-Sided Congestive Heart Failure

 Blood Dams Back From the Right Ventricle to Right Atrium

Pressure of Blood Into the Pulmonary Capillary Bed Increases

Increased pressure in the Venous Circuit

Signs and Symptoms:

Jugular Vein Distention (Neck Vein Engorgement), Hepatomegaly, Portal Hypertension,
Ascites, Peripheral Edema, Splenomegaly, Jaundice, Leg Varicosities, Enlarged Internal
Hemorrhoids, Weight Gain S3S4 Heart Sounds
 COLLABORATIVE MANAGEMENT
1. MEDICATIONS

A. Digitalis Therapy
 It is the major therapy for CHF
 helps an injured or weakened heart pump more efficiently
 It has Positive Inotropic Effect
 It has Negative Chronotropic Effect
 Negative Dromotropic Effect
 Assess heart rate before administration of digitalis
(with hold if the the heart rate is 60 bpm or below and 120 bmp and
above since bradycardia or rebound tachycardia may occur)
Monitor serum potassium (K) level – Normal Value 3.6 to 5.2
millimoles per liter (mmol/L)
 Hypokalemia enhances digitalis toxicity because it potentiates the
effect of the drug
E.g 1. Lanoxin (Digoxin), 2. Crystodigin (Digitoxin),
3. Lanatoside C ( Cedilanid C), 4. Deslanoside (Cedilanid D)

Evaluate the effectiveness of digitalis

 there should be increased cardiac output, increased urine output,
stronger pulse, lowering of Blood Pressure, absence of crackles
and rales)
  Assess for signs and symptoms of Digitalis Toxicity:
 Bradycardia
 Nausea and Vomiting/ Diarrhea
 Dysrhythmias (most dangerous)
 Altered Visual Perceptions (yellow/green vision; blurred
vision, halos or rainbows around lights among elderly)
In males: Antiandrogenic Effect
Gynecomastia, Decreased Libido, Erectile Dysfunction

 The Therapeutic serum level of Digoxin is 0.5 to 2.0 ng/ ml

 Antidote for digitalis toxicity: Digoxin Immune Fab
(Digibind)
B. Diuretic Therapy

 purpose: decrease cardiac workload by reducing circulating volume

and thereby reducing preload
 Assess for s/sx of hypokalemia when administering thiazides and loop
diuretics
 Give Potassium supplement and potassium-rich foods
 Diuretics are best administered early in the morning or early afternoon
to prevent disturbance related to nocturia
 If thiazides are ineffective, an oral Aldosterone antagonist (blocks the
aldosterone receptor sites) may be given with Thiazide
The Diuretics used in the treatment of CHF are:
a. Thiazides ( Potassium-wasting )
1. Chlorothiazide (Diuril)
2. Hydrochlorothiazide (Esidrix, Hydrodiuril)
b. Loop Diuretics ( Potassium-wasting )
1. Furosemide (Lasix)
2. Bumetamide ( Bumex)
c. Potassium-Sparing Diuretics
1. Spironolactone (Aldactone)
2. Triamterene (Dyrenium)
C. Vasolidators

 purpose: to decrease afterload by decreasing resistance to ventricular

emptying

Most commonly used drugs:

1. Nitroprusside (Nipride) – (direct-acting vasodilator)

2. Hydralazine (Apresoline) -(vasodilator)
3. Nifedipine ( Calcium-Channel Blocker with vasodilator effect)
4. Captopril (ACE- Inhibitor) also has a vasodilator effect
D. Other Drugs (Sympathomimetics)

 usefulin the treatment of patients with ischemic heart disease

complicated by heart failure
 have a direct positive chronotropic effect on heart rate
 

Most common drugs:

 Dopamine
 Dobutamine
 NURSING INTERVENTIONS
1. Providing Oxygenation

 To increase oxygen supply

 Administer oxygen therapy per nasal cannula at 2 to 6 L/min as
ordered
 Evaluate arterial blood gas analysis results
 Check Oxygen saturation as ordered
 Maintain semi-Fowler’s or High Fowler’s Position to maximize
oxygenation by promoting greater lung expansion
2. Promoting Rest and Activity

 Balanced Program of activity and rest. Bed rest or limited

activity may be necessary during the acute phase
 Provide an overbed table close to the patient to allow resting the
head and arms
 Arms may be supported on pillows to reduce the pull on the
shoulder muscles when in High-Fowler’s position which is most
comfortable for the patient
2. Promoting Rest and Activity

Administer Diazepam (Valium) 2 to 10 mg for 3 to 4 times a day

as ordered to allay apprehension
 Gradual ambulation is encouraged to prevent risk of venous
thrombosis and embolism due to prolonged immobility
 Activities should progress through dangling, sitting up in a chair
and then walking in under close supervision
Assess for activity intolerance such as DOB, fatigue and
increased pulse rate that do not stabilize easily
3. Decreasing Anxiety

 Identifying feelings and concerns related to these feelings

 Identify strengths that can be used for coping
 Learn what can be done to decrease anxiety
 Anxiety causes increased breathlessness which may be perceived
by the client as an increased in the severity of the heart failure and
this in turn increases the anxiety
4. Facilitating fluid balance

 Limit Fluid intake as indicated

 Control of Sodium (salt) intake
 Administer diuretics and digitalis as prescribed
 Monitor intake and output
 Monitor Weight and Vital signs
5. Providing Skin Care

 Edematous Skin is poorly nourished and susceptible to pressure

sores
 Change position at frequent intervals
 Assess the sacral area regularly for pressure sores (this is the center of
gravity when the patient is bedridden)
 Use protective devices to prevent pressure sores
6. Promoting Nutrition

 Diet: Sodium restricted (Low Salt) diet to prevent fluid excess.

”No added Salt” diet is prescribed
 Salty Foods must be omitted
 Provide Bland, Low Calorie, Low Residue diet with vitamin
supplement during acute phase
 Frequent Small feeding minimize exertion and reduced
gastrointestinal blood requirements
7. Promoting Elimination

 Advise client to avoid straining at defecation which involves

Valsalva’s Maneuver (this increases cardiac workload)
 Administer Laxative as ordered:
 E.g Colace (Docussate Sodium), Senokot (Senna)
 Encourage to use bedside commode (this requires lesser cardiac
workload than using bed pan)
 Avoid using the bedpan since it involves lifting the hips (use of
Valsalva maneuver) which increases cardiac workload
8. Facilitate Learning

 Teach the client and family about the disorder and self-care
 Monitor signs and symptoms of recurring CHF (e.g weight gain, loss
of appetite, dyspnea, orthopnea, edema of the legs, persistent cough)
report to the physician
 Avoid fatigue, balance rest with activity
 Observe prescribed sodium restrictions
 Eat small, frequent meals rather than 3 large meals a day
 Take prescribed medications at regular basis ( digitalis, diuretics,
vasodilators)
9. If with acute pulmonary edema occurs in CHF, these
are the appropriate collaborative management

 Place in high-fowler’s position with legs slightly lowered to facilitate

breathing and to reduce preload
 Morphine Sulfate 10 to 15mg/IV as ordered ( to primarily reduce
preload by venous dilation and afterload arterial dilatation and to allay
anxiety
 Oxygen therapy at 40% to 70% by nasal cannula or face mask
 Aminophylline IV as ordered ( to relieve bronchospasm, increase
urine output and increase cardiac output)
 Rapid Digitalization (the administration of digitalis in a dosage
schedule designed to produce and then maintain optimal
therapeutic concentrations of its cardiotonic glycosides)
 Diuretic Therapy
 Vasodilators
 Dopamine and Dobutamine
 Monitor serum potassium